19-year-old male patient admitted from the emergency department for a gunshot wound (hunting shotgun) after an attempt at autolysis (impact distance less than one metre). He presented with a wound in the lower third of the lateral region with significant bone loss from the left first premolar to the left mandibular angle. Significant cutaneous and mucosal loss of the left jugal region and left cheek. Tracheotomy, debridement of devitalised tissues, splinting of teeth, intermaxillary block and placement of a mandibular reconstruction plate.
Direct intraoral closure and skin closure with a cervicofacial advancement flap were carried out during this first surgical stage.
In the immediate postoperative period, there was suffering and loss of the cervicofacial advancement flap, leaving a significant left facial granulating area. Scar retraction of the oral mucosal tissue results in severe limitation of the oral opening (0.8 cm). There are orofacial communications and salivary fistulas.
Secondary intervention is decided by means of a scapular-parascapular osteomyocutaneous flap of the left arm, non-dominant, but with a history of recurrent dislocation.
The operation began with a new tracheotomy and preparation of the recipient vessels: facial artery and branch of the thyrolinguinguofacial venous trunk. It is necessary to remove a large amount of cellular-ganglionic tissue from level I and III, in order to reach the recipient vessels.
The osteocutaneous scapular-parascapular flap is then dissected and the donor area is closed, leaving suction drainage and immobilising the left upper limb with a sling.

The bony part of the flap is then adapted to the mandibular defect with ostosynthesis using the reconstruction plate placed in the initial operation. The cutaneous part of the flap is folded like a book, leaving one of the cutaneous lobes intraoral and one extraoral (cervical facial). The back of the so-called book is de-epithelialised and sutured to the remaining lower lip. The intraoral part reconstructs the entire jugal mucosa up to the anterior pillar of the soft palate. The external part reconstructs the mandibular and left submandibular skin area. The posterosuperior region of the skin defect is left for dermoepidermal grafting. The block and the dental splint are removed and the mouth is left "open".

Adaptation of the flap required submaxillectomy and removal of some of the posteroinferior subcutaneous tissue.
The anastomosis was made end-to-end from the scapular circumflex artery to the facial artery; and from the greater of the scapular circumflex veins to the thyroinguinguofacial trunk.
The duration of the operation was 14 hours, with an ischaemia time of 2.45 hours.
Satisfactory evolution regarding the vitality of the scapular flap. Local complications: parotid salivary fistula in the posterosuperior area due to loss of the dermoepidermal graft over the maseterine region.

Complications in the donor area: disinsertion of the long arm of the triceps and wound dehiscence. To treat this dehiscence, the patient underwent a local transposition graft. Postural complication: paralysis of the radial nerve on the contralateral (right) side.

The patient is undergoing rehabilitation treatment to regain mobility of the left arm.

